Critical care clinics
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End stage liver disease results in a complex and variably severe failure of hemostasis that predisposes to abnormal bleeding. The diverse spectrum of hemostatic defects includes impaired synthesis of clotting factors, excessive fibrinolysis, disseminated intravascular coagulation, thrombocytopenia, and platelet dysfunction. ⋯ Correction of hemostatic defects is required in patients who are actively bleeding or require invasive procedures. Fresh frozen plasma, cryoprecipitate, and platelet transfusion remain the mainstays of therapy until larger trials confirm the safety and efficacy of recombinant factor VIIa in this population.
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Disseminated intravascular coagulation (DIC) is a syndrome characterized by a systemic activation of coagulation leading to the intravascular deposition of fibrin in the (micro) vasculature and the simultaneous consumption of coagulation factors and platelets. The occurrence of microvascular thrombosis as a consequence of DIC is underscored by pathological, experimental and clinical findings, demonstrating a link between DIC and organ dysfunction. Pathogenetic pathways that play a role in the development of DIC include tissue factor-dependent activation of coagulation, defective physiological anticoagulant pathways (such as the antithrombin system and the protein C system), and impaired fibrinolysis, caused by elevated levels of plasminogen activator inhibitor type 1. Novel therapeutic strategies are based on current insights into the pathogenesis of DIC, and include anticoagulant strategies (eg, directed at tissue factor) and strategies to restore physiological anticoagulant pathways (such as activated protein C concentrate).
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Acute renal failure in critically ill patients is a growing clinical problem. Options for renal replacement therapy in these patients use convective and diffusive clearance and may be intermittent, as in classic hemodialysis, or continuous. ⋯ It may be that renal replacement therapy needs to be tailored to the needs of each individual patient. Current and future research studies should provide the answers to many of these questions.
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An advanced understanding of acid-base physiology is central to the practice of critical care medicine. Intensivists spend much of their time managing problems that are related to fluids, electrolytes, and blood pH. ⋯ All changes in blood pH, in health and in disease, occur through changes in these three variables. This article reviews the physical-chemical approach to acid-base balance and considers clinical implications for these findings.
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Critical care clinics · Jan 2005
ReviewManaging infection in the critical care unit: how can infection control make the ICU safe?
The goal of this article is to use ventilator-associated pneumonia (VAP) as a prototype for nosocomial infections to explore the issues of patient safety and infection control. To do this, we review disease-specific aspects of VAP, develop a brief working definition of patient safety, and then determine how the concepts of infection control fit into the broader context of patient safety.